Pediatric Physician. and Advanced Providers Handbook. for Inpatient Cerner Use

Transcription

1 Pediatric Physician and Advanced Providers Handbook for Inpatient Cerner Use Section Last updated Page(s) Background Jan-13 2 Admission Process Nov Codes Nov Discharge Process Nov Downtime Procedures Nov Orders - Medical Student Nov Orders - Pediatric Call Orders Jan-13 7 Orders - Pediatric Powerplans Jan-13 6 Orders - Planning and Initiating Jan Orders - Verbal Nov Pediatric CPOE/EHR Change Management Jan-13 9 Prescriptions Nov-12 8 Riley Provider Support for CPOE/EHR Nov Terminology Nov-12 3 Transfers - OR Nov Transfers Inter-facility Nov Transfers - Medical Nov

2 Background Pediatric CPOE for inpatients was initiated at multiple IU Health facilities in August Content was developed by pediatricians, nurses, and pharmacists across all facilities. This handbook is a reference tool for physicians and advanced providers regarding several parts of the Cerner based electronic health records (EHR). Cerner is the vendor product for all pediatric CPOE at IU Health. Clinics and other locations (such as outpatient surgery and other care settings) are not all using Cerner at this time; appropriate steps should be taken by all providers planning to care for pediatric inpatients at IU Health locations. 2

3 Terminology Powerplan Powerplan phases Add to phase Planned state Initiated state Subphase or mini Single order Powernote Powerform Encounter Virtual bed Medication list Medication reconciliation EDI (electronic discharge instructions) Grouping of physician orders. Powerplan is a Cerner term; on paper or more generically, this was called an order set or admission orders. A Powerplan has specific properties within Cerner (see below). Multiple parts of the same Powerplan Allows physician to add an order that will be grouped with a Powerplan phase Powerplan is filled out by physician and saved. Not active. Activated Powerplan. Small groups of orders. May be linked to Powerplans or stand alone. Cannot be embedded or added directly to a Powerplan Order that is not included in a Powerplan or subphase. Clinical progress note Documentation tool for complex orders, plans or standardized documentation. Pediatric examples include: TPN orders, asthma action plans, and screen for influenza vaccination. Patient visit (ie. A clinic visit, an ED visit, an inpatient stay) Unique patient location to designate inpatient status. Allows for inpatient orders if physical space is not yet ready. Often used in the ED or clinics. List in Cerner that includes any prescriptions (acute and chronic), medications by history (documented only), and inpatient medications (active orders) Review of medications. Completed any time a review is done, but must be documented at admission, transfer and discharge Instructions for inpatient discharges generated in Cerner, includes a printed medication list 3

4 Planning and Initiating Orders Within the same hospital, different providers (doctors, nurses and pharmacists) will view orders and have different ways to process information. Some basic differences between the planned and initiated state of orders should be considered. What is the basic difference? How might I use them? Who sees them? Why are there these differences? Planned state Powerplans in a planned state are filled out by physician and saved. They are visible to some providers, but not active; that is, they do not produce tasks to nurses or communications to pharmacy. Powerplans in a planned state need to be initiated to be used. Using the planned state allows me to prewrite orders that I know I will be using once a patient arrives for care. Powerplans in a planned state may be seen by other providers, but are not highlighted in all Cerner tools. Example: - PACU nursing staff use Powerchart to look for the post-op phase of orders - ED staff use FirstNet. STAT orders are highlighted; however, Powerplans in a planned state may be found by searching. Viewing Powerplans in a planned state is only part of the patient care in some areas, so not everyone does it. For example, Powerplans in a planned state for future chemotherapy may incorrectly be initiated early if everyone was viewing them. Initiated state Initiated plans are visible to all providers and active; they produce task for nursing and pharmacy. Initiated Powerplans are the active orders on the patients. Modifying them changes the active request to nursing and pharmacy. All providers have the orders from initiated Powerplans visible and highlighted; however, there are different ways to sort and view orders depending on the provider and their job. Doctors, nurses and pharmacists have different views to reflect different roles and workflow. 4

5 Planning and Initiating Orders (cont.) Who is responsible at these phases? The physician is ultimately responsible for communicating all orders and the care plan to the team. Initiating orders is the physicians responsibility unless other staff has been specially trained to initiate their orders. At Riley, for example, the only time the physician does NOT initiate a Powerplan in a planned state is postoperatively. In that setting, the PACU nurses have been trained to initiate the post-operative phase of multiple phase Powerplans. In the cases when a patient is transferred directly to the ICU setting (NICU or PICU), the ICU nursing staff must be informed of the postoperative orders and may be able to initiate planned orders if the physician directly communicates with them. However, routine practice is that the physician assumes responsibility for initiating all orders outside of routine PACU postoperative phase Powerplans. 5

6 Pediatric Powerplans These plans were developed by pediatric physicians, nurses and pharmacists to address best practice during admissions and pediatric specific needs. Comprehensive and most updated list of frequently used pediatric Powerplans is found on the physician education website. There are several pediatric specific subphases to highlight, including: - Antibiotics subphases o These include optimum doses for different indications as well as weight-based recommendations - Acute intermittent pain medications subphase o Includes recommended doses as well as side effect management - Single dose vaccinations for inpatient use subphases o Includes reference materials to determine which vaccines are indicated - Pediatric call orders subphase o These age-specific orders are included as default in some Powerplans o Please see separate module for further details - VTE prophylaxis subphase - Blood products o Tranfusion of PRBCs and platelets subphase o Tranfusion of cryoprecipitate and other products subphase 6

7 Pediatric Standard Call Orders Subphase - Standard pediatric call orders were developed to promote age-based call orders for temperature, heart rate, respiratory rate, blood pressure and oxygen saturation - To change or modify the call orders, the physician must uncheck the pediatric standard call orders subphase, and select the subphase below - If you select more than one set of call orders, this may produce conflicting and confusing orders; select only one set of call orders - The subphase will be modified in the future to clarify that ONLY ONE set of call orders should be selected. See the text below for an example: Call Orders Click on reference text below to review details of the Standard Pediatric Call Orders for Age Standard Pediatric Call Orders for Age OR If you need to enter different parameters for your patient, uncheck Standard Pediatric Call Orders above and select the Modifiable Pediatric Call Orders Subphase below. ATTENTION: Do NOT check both options as this will result in duplicate call orders. Modifiable Pediatric Call Orders Updated The call order values may be accessed by clicking on the reference text in the subphase - FAQ: Pediatric Call Orders 7

8 Prescriptions - Most pediatric settings do not yet allow for true e-prescribing (in which the prescription goes directly to the pharmacy), but all inpatient pediatric settings support computer-generated prescriptions - All printers for computer generated prescription printing are labeled as Prescription Printer or RX Printer capable. They are centrally located in the Copy rooms in the SFT and in the nursing stations of the other units - Printing occurs on special paper from the second drawer. This is set up in the program once you select the printer - If the drawer is out of paper, the Unit Secretary can assist in getting supplies as the special paper for printing prescriptions will be kept in a locked location on the unit - All paper prescriptions, whether computer generated or hand written, must be signed by hand - There are many printers in the hospital; to increase your efficiency, set your most frequently used printers as favorites FAQ - Adding Favorite Prescription Printers / Changing Default Printer 8

9 Pediatric CPOE/EHR Change Management PediPOG (pediatric protocols and orders group) is a group of physicians, nurses, and pharmacists who review all pediatric content before it is changed or built in Cerner pedipog meets monthly and may meet more frequently when needed PediPOG works collaboratively with a pediatrics clinical informatics team to prioritize and optimize content and then submit to System IS or appropriate governance for follow-up Change requests should submitted via the Pulse page Riley PowerPlan Revision Request Form For questions or inquiries, PediPOG uses a common account [email protected] Requests that have system-wide impact may require COPOG review View a listing of pedipog contacts/group members here: 9

10 Riley Provider Support for CPOE/EHR Basics All MDs and NNPs must complete training prior to receiving CPOE Cerner security access CPOE Cerner security access is centrally controlled and may take up to 48 hours business hours to be completed Physician, NP and PAs: On-boarding, training and support Tracie Anderson, Physician Education Liaison to Riley Hospital for Children, Center for Physician Education or Center for Physician Education, main line for general Cerner training: , Training modules, FAQs, and the Cerner Handbook can be found on the Physician Education Website CPOE status change Providers who have completed web-based assessment should notify data security through the Help Desk, , Monday through Friday, This should be completed at least 2 days PRIOR to start of service at Riley IU Health Service Desk Service desk functions include: password resets, hardware problems, order entry, documentation and Cerner display problems Issues should be documented through the IU Health Service Desk, which is available 24/7. This is important so that system issues can be identified and fixed efficiently. You will be asked for contact information so that the issue can be tracked and completed. (317) or [email protected] The Help Desk will access the appropriate application support team for resolution. These teams take call and are available 24 X 7 for emergent issues. 10

11 Admission Process - Patients may be admitted directly from home, an outside clinic or hospital, a Riley clinic, or the ED - As always, communication is key to a successful and efficient admission - Depending on patient location, effective and timely admission may involve different processes. Highlights of this process include: Transfers Admission medication reconciliation must be completed regardless of where patient is coming from. FAQ: Admission Medication Reconciliation Physicians admitting patients from the Riley ED should status orders to be done in the ED as STAT and initiate them. FAQ: Admission from Riley ED Powerplans in a planned state may be started using a previous encounter, but will be visible on all subsequent encounters. Admission orders are not active until they are initiated. Outside of post-operative phases in the PACU, initiation of orders is a physician responsibility. - The transfer process at Riley uses two different forms: o Medical wards use the Transfer Order Review in Cerner o Transfers to and from the OR use the Transfer Order Summary (TOS) generated under the reports tab in Cerner - OR: The information below may also be accessed here: Management of the Surgical Patient Workflow - Medical: This information may be accessed here: Key Steps in Transferring Patients To/From the ICU Key Steps in Transferring Patients from One Level of Care to Another 11

12 Flowsheet: Medical Transfers within Riley downtown campus 12

13 Inter-facility Transfers - As always, communication is key to a successful and efficient transfer - Between IU Health facilities, Powerplans may be placed in a planned state, and initiated later - Not all facilities have the same views of specific Powerplans, medications and other orders Discharge - The Discharge Instructions tab (ie. the EDI ) in Cerner should be used to discharge inpatients - As always, communication is key to a successful and efficient discharge - Update the Medication list prior to creating the discharge medication list in the Discharge instructions tab - FAQ: EDI Tips 13

14 Downtime Charting that occurs during downtime (notes, orders, etc.) should occur on paper that will later be scanned into the patient s medical record. Access the full IU Health (CP 1.30AP) policy on the Pulse page by searching Downtime. Physician Order entry: During the downtime, all new orders should be written. - Order sets (ie.paper versions of Powerplans s) may be printed from Pulse - There will be inherent differences in the information needed to correctly complete a paper form, versus a Powerplan in Cerner - For single orders, you may use a blank Physician s Order sheet available on the unit of printable form Pulse - Give the Order sheet to the Unit Secretary/Nurse who will carry out orders following their usual Downtime process Physician Documentation: During the downtime all documentation should be written on a History Physical Progress Other Note. - When completed, place the paper documentation on the patient s paper chart. - This will be scanned into Cerner to the patient s medical record after the system is back up. Downtime Reports - Downtime Reports may be used to view and print patient data during Cerner downtime and are available on designated computers on each unit with a sticker labeled Downtime Workstation - Information available through the Downtime Reports folder will display the most current patient data (from 1-12 hours old) - Downtime Reports folder does not contain your personal patient list but you can print or view a Rounds Report, Vitals, I&O detail, Lab Results, Last Charted Notes, Chart Summary, Active Orders, Discharge Instructions (only if they have an entry prior to downtime) and a MAR 5 day with documentation of Meds from the past 5 days - You may also request a unit census list from the Unit Secretary. 14

15 Printing a Downtime Report 1. Find the designated Downtime Workstation on the unit where your patient is located. (This is often the unit secretary s computer, and the unit secretary may be able to print the report for you.) 2. Open the Downtime Reports folder by clicking on the icon located on the computer desktop. 3. You will be required to type in a password. The password is: downtime. 4. The Downtime Reports folder will display a list of reports for patients registered to this patient care area. 5. Click on the desired report to view the information for the entire unit. Scroll to your patient and you may view or print the pages associated with that particular patient s report. INPC (CareWeb) INPC is a data repository containing patient information. If Cerner is down and the Network is still up, you will be able to access the usual patient information found in INPC. Different data may upload at different times from the INPC. To access INPC during downtime: 1. Open the Clarian Applications folder on the desktop and click on the INPC icon 2. Complete the following fields: User ID you must enter your INPC ID Password enter your INPC password 3. Click the Login button. 15

16 Medical Student Orders - 3 rd and 4 th year medical students on medical teams at Riley will be able to enter orders, but NO medical student orders are active until approved by a resident or attending physician - ALL medical student orders will be identified with a special icon and status of med student on hold - Nursing and pharmacy staff will be able to see orders written by medical students but will not act on the orders until they are verified by a physician - Staff physicians will see these orders in their Cerner inbox, but ANY physician can sign them Verbal Orders - Physicians, nurses and pharmacists at Riley should adhere to IU Health Verbal orders policy, MS 3.22 Verbal Orders - Verbal orders will only be accepted: o In emergencies (ie. Codes, see above) o When the physician does not have access to a computer o When the medical record or electronic order system is unavailable - Verbal orders should be reserved as much as possible for emergent/urgent situations Written orders - Are expected and acceptable during downtime Patient care comes first. When in doubt, use your clinical judgment, communicate and cooperate. 16

17 Codes - All code situations will be documented on paper - Orders will NOT be entered retroactively after a code 17